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PubMed2001

Atrial size reduction as a predictor of the success of radiofrequency maze procedure for chronic atrial fibrillation in patients undergoing concomitant valvular surgery.

INTRODUCTION: Previous studies showed that the surgical maze procedure can restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation (AF). However, no previous studies discussed the association of atrial size reduction and the success of sinus conversion by the radiofrequency (RF) maze procedure for chronic AF. METHODS AND RESULTS: A total of 119 chronic AF patients undergoing valvular operations were included in this study. Sixty-one patients received RF and cryoablation to create lesions in both atria to simulate the surgical maze II or III procedure (RF maze II or RF maze III; 13 patients, group 1) or a modified maze pattern (RF maze "IV"; 48 patients, group 2). The other 58 patients who underwent valvular operations alone without the maze procedure served as control (group 3). At 3-month follow-up after operation, sinus rhythm was restored in 73%, 81%, and 11% of patients in groups 1, 2 and 3, respectively. Preoperative left and right atrial sizes were not statistically significant predictors of sinus conversion by the RF maze procedure. However, as a result of postoperative reduction of atrial sizes, postoperative left atrial diameter was significantly smaller in patients who had sinus conversion by the RF maze procedure than in patients who did not regain sinus rhythm (45.0+/-7.0 mm vs 51.0+/-8.0 mm; P = 0.03). Postoperative right atrial area of patients who had sinus conversion by the RF maze procedure also was significantly smaller than that of patients who did not regain sinus rhythm (18.1+/-4.4 cm2 vs 28.5+/-8.2 cm2; P = 0.008). CONCLUSION: Atrial size reduction appears to predict the success of sinus conversion with the RF maze procedure used in conjunction with valvular surgery.

Adult↗
PubMed2002

Antibiotic prophylaxis for dental or urological procedures following hip or knee replacement.

OBJECTIVES: Reports of prosthetic joint infection associated with urological or dental procedures have prompted suggestions that these patients require antibiotic prophylaxis, but no guidelines have been agreed. We have polled orthopaedic surgeons, urologists, and dentists on this issue. METHODS: The questions asked were: could infection of a joint prosthesis result from a dental or urological procedure; does the risk of infection warrant patients informing their dentist or urologist about their joint replacement; should these patients have prophylactic antibiotics for (a) routine procedures and (b) lengthy procedures. RESULTS: Urologists and orthopaedic surgeons agreed that infection could probably result from urological procedures and that patients should definitely inform their urologist about their prosthesis. Orthopaedic surgeons thought that antibiotics were definitely indicated for routine and lengthy urological procedures while urologists thought antibiotics were probably indicated. Orthopaedic surgeons thought that infection probably could result from dental procedures, while dentists answered "don't know". Both groups agreed that patients should definitely inform their dentist about their prosthesis. Orthopaedic surgeons thought that antibiotics probably were necessary for routine and lengthy dental procedures, whereas dentists answered "probably not" and "don't know", respectively. CONCLUSIONS: These results could provide the basis for a consensus regarding prophylactic antibiotic use in this growing patient population.

Anti-Bacterial Agents↗
PubMed2000

What is the relative frequency of uncommon ambulatory surgery procedures performed in the United States with an anesthesia provider?

UNLABELLED: Between 1994 and 1996, the National Center for Health Statistics used sophisticated sampling methods to measure the number and types of ambulatory surgery cases performed in the United States. We reanalyzed raw data obtained from this National Survey of Ambulatory Surgery to select cases with an anesthesia provider and here report characteristics of these 228,332 cases (e.g., patient age, anesthetic type). The goal of our study was to estimate what percentage of cases, of a specified surgical procedure or combination of procedures, may have been performed less than once per year per facility. Previous studies suggest the most important source of scheduling inaccuracy can be the absence of recently performed cases on which to base predictions of case duration. We found that 36% +/- 1% (SE) of all cases in the United States were a type of procedure or combination of procedures that occurred <6984 times per year (the number of surgery facilities performing ambulatory surgery in the United States). Approximately one third of all ambulatory cases were of a procedure or combination of procedures that may have been performed as infrequently as once per year per facility. This could impair the effectiveness of predicting the durations of ambulatory cases by using historical case-duration data. IMPLICATIONS: Approximately one third of all ambulatory cases were a procedure or combination of procedures possibly performed as infrequently as once per year per facility. This could impair the effectiveness of predicting the durations of ambulatory cases by using historical case-duration data.

Adolescent↗
PubMed2004

Differentiating among hospitals performing physiologically complex operative procedures in the elderly.

BACKGROUND: The authors previously showed how a statewide discharge abstract database could be used to quantify for stakeholders how surgical practices differ among hospitals. The two pediatric hospitals in Iowa differ from other hospitals in Iowa based on their providing a more diverse, comprehensive, and physiologically complex selection of procedures in younger patients. Physiologically complex surgery performed in children aged 0-2 yr has been regionalized to a few high-volume facilities. METHODS: The same inpatient discharge abstract database was used to quantify physiologically complex operative procedures performed throughout Iowa in patients aged 80 yr and older during January through June 2001. RESULTS: In contrast to earlier results with pediatric patients using the same database, hospitals performing physiologically complex procedures in the elderly could not readily be differentiated from one another based on the numbers and types of procedures performed (P < 0.001 when comparing geriatrics vs. pediatrics in terms of the distributions of numbers of procedures, the distributions of numbers of different types of procedures, or the distributions of numbers of rare procedures performed at different hospitals). Additional analyses showed that one hospital did perform relatively more rare procedures in geriatric patients and had a relatively larger percentage of patients who traveled beyond their local county to reach it. CONCLUSIONS: Results observed for geriatric patients provide further evidence of the validity of these methods and the usefulness of discharge abstract data for comparing surgical practices among facilities. A hospital can use discharge abstract data to assist governmental agencies, charitable organizations, philanthropists, insurers, etc., in appreciating the unique contributions of individual hospitals to surgical care.

Aged↗
PubMed2001

Complications of epilepsy surgery after 654 procedures in Sweden, September 1990-1995: a multicenter study based on the Swedish National Epilepsy Surgery Register.

OBJECTIVE: To present the first national multicenter study on complications after epilepsy surgery procedures to include all epilepsy surgery centers in Sweden: Göteborg, Linköping, Lund, Stockholm, Umeå, and Uppsala. METHODS: Every epilepsy surgery procedure in Sweden is reported to the Swedish National Epilepsy Surgery Register. The report includes relevant social and medical items and complications. A complication is defined as minor if it resolves within 3 months and major if it affects activities of daily living and lasts longer than 3 months. Follow-up data are recorded for 2 years after the operation. Intrinsic checkpoints and external revision validate the register data. RESULTS: During the inclusion period (September 1990-December 1995), 654 surgical procedures were performed (age range, 6 mo-67 yr). Of these, 205 were invasive electrode procedures (182 first investigations and 23 reinvestigations), and 449 were therapeutic procedures (375 first operations and 74 reoperations). After invasive electrode procedures, only minor complications were reported (6.3%). For all 449 therapeutic procedures (including reoperations), minor complications were reported in 8.9% and major complications in 3.1 %. Only one major complication was reported in a patient under the age of 35 years. CONCLUSION: This is the first national multicenter study on complications after epilepsy surgery. It demonstrates that these procedures as performed at six different centers in Sweden are safe, but also that risk is related to age. In patients younger than age 35 years, the risk for a major complication after invasive subdural strip electrode investigation and epilepsy surgery is low.

Adolescent↗
PubMed2005

Hartmann procedure: is it still relevant today?

BACKGROUND: With more and more centres worldwide resorting to primary anastomosis for most left sided colonic pathology, the place for a Hartmann procedure seems to be relegated to surgical history books. However, in our centre it is still being performed on a regular basis. As such, we decided to retrospectively look at our results for the procedure. METHODS: All hospital records of patients undergoing the Hartmann procedure between January 1998 and December 2001 were retrospectively analysed looking at demographics, comorbidities and indications of the procedure. RESULTS: There were 52 men and 33 women with a median age of 69 years (range 31-96 years). Sixty-six per cent of the patients had medical comorbidities at the time of the operation. The indications for performing the procedure were: 45 patients for cancer (31 patients for obstruction, 11 patients for perforation, two patients for fistulation to other organs and one for uncontrollable bleeding). 19 patients had the procedure for complicated diverticulitis while four patients had anastomotic leaks, which required conversion to the procedure. Other indications include trauma (four patients), ischemic bowel (six patients) and iatrogenic (one patient). Our median operating time was 160 min (range 50-415 min). Our reversal rate was 32%. Our mortality rate for the first stage was 16% and our morbidity, 51%. The morbidity for the reversal was 29%, with no mortalities. CONCLUSION: Though the idea of primary anastomosis with on table lavage for left sided anastomosis seems attractive, we think the Hartmann procedure is still useful for selected patients.

Adult↗
PubMed1994

Low cost, patient acceptable, local analgesia approach to gynaecological outpatient surgery. A review of 817 consecutive procedures.

UNLABELLED: The objective of this study was to evaluate safety, cost effectiveness and patient acceptability, of performing a wide variety of gynaecological procedures, including endometrial resections, in a clinic using only local analgesia. Eight hundred and seventeen consecutive gynaecological procedures were performed under local analgesia only, with no sedation, including endometrial resections, cone biopsies, terminations of pregnancy, hysteroscopies, and local vaginal and plastic vulval procedures, as well as many combined procedures (figure 1) in a day-surgery ward annexe in the Department of Gynaecology, St John's District General Hospital, Chelmsford Essex. The main outcome measures were patient acceptability, safety and encountered side-effects of procedures performed under local analgesia as well as evaluation of cost-effectiveness and reduction in theatre waiting list times. A high degree of safety and patient acceptability was achieved, with other considerable benefits being short waiting times and much quicker recovery. The only complications were from the endometrial resection group, with only 8 (3.6%) of these requiring intravenous sedation intraoperatively, and 6 (2.7%) requiring overnight admission. No transfers to theatre during any procedure occurred. Savings per procedure, in cost and in patient's time, were very considerable. CONCLUSION: The local analgesia approach for a wide variety of gynaecological procedures in a combined outpatient theatre is safe and is highly acceptable to patients. There are also considerable benefits in cost and patient convenience, with a reduction in operating list waiting time, which in the current economic climate are worth considering.

Ambulatory Surgical Procedures↗
PubMed2006

Radiation doses from venous access procedures.

PURPOSE: To retrospectively analyze radiation dose data for six common venous access procedures. MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant study; informed consent was not required. Data review was limited to a quality assurance database. Patient medical records were not reviewed. We retrospectively analyzed radiation dose data from a prospective quality assurance program. Dose data were analyzed for 1010 instances of six different venous access placement procedures performed between February 1998 and July 2004. Radiation dose measurements were generated automatically by the interventional fluoroscopy units and were recorded at the conclusion of each procedure. Descriptive and summary statistical analyses were performed to determine median, minimum, and maximum values of radiation dose for each procedure. A P value of less than .05 indicated a significant difference. Because the data distribution was highly skewed, logarithmic transformation was performed. Dose data for four different venous access procedures (excluding chest port placement and peripherally inserted central catheter placement) were compared with a one-way analysis of variance. Pairwise comparisons with the Tukey honestly significant difference test were subsequently performed for each analogue where analysis of variance demonstrated a significant result. RESULTS: No procedure yielded a cumulative dose of more than 950 mGy or a peak skin dose of more than 760 mGy. The highest mean cumulative dose (ie, 88 mGy), mean dose-area product (ie, 873 cGy . cm(2)), and mean peak skin dose (ie, 43 mGy) were observed for tunneled dialysis catheter placements. Significant differences in dose were observed for tunneled catheter placement versus nontunneled catheter placement (<.001 to .027). No significant differences in dose were observed for larger-diameter versus smaller-diameter catheters. CONCLUSION: Radiation doses from venous access procedures are low. Even extreme outlier cases are unlikely to produce doses high enough to cause skin effects, especially when knowledgeable operators using well-calibrated equipment perform the procedures.

Analysis of Variance↗
PubMed2026

Ketamine Plus Midazolam versus Fentanyl Plus Midazolam for Sedation and Analgesia during Image-guided Procedures in Interventional Radiology: Randomized Clinical Trial.

Background Opioid-benzodiazepine regimens remain common for radiologist-administered procedural sedation despite respiratory and analgesic effectiveness concerns. Purpose To compare intraprocedural pain and patient-reported experience between ketamine/midazolam and fentanyl/midazolam during image-guided procedural sedation. Materials and Methods This randomized clinical trial was conducted at a single academic center between June 2025 and February 2026. Adults undergoing image-guided lung or bone biopsy or abscess drainage were randomized to fentanyl/midazolam or ketamine/midazolam administered by interventional radiologists. Procedures were performed using US, CT, CT fluoroscopy, or combined CT and US guidance. The primary outcome was maximum intraprocedural pain (0-10 on the Numeric Rating Scale). Secondary outcomes included sedation depth, physiologic parameters, oxygen desaturation, patient-reported experience assessed using a modified Heidelberg questionnaire, and complications. Results Among 264 randomized procedures (132 procedures per group) in 260 participants (median age, 68 years [IQR, 61-75 years]; 135 [52%] female), ketamine/midazolam resulted in lower maximum intraprocedural pain than fentanyl/midazolam (mean difference, -1.4 points [95% CI: -2.0, -0.8]; P < .001). Pain scores greater than 4 occurred less frequently with ketamine/midazolam (2.3% vs 17%; absolute difference, 14 percentage points [95% CI: 8, 21]; P < .001). Ketamine/midazolam was associated with higher nadir oxygen saturation (mean difference, +1.4% [95% CI: 0.6, 2.2]; P = .001) and fewer oxygen desaturation events below 90% (three [2.3%] vs 13 [9.8%]; absolute difference, 7.6 percentage points [95% CI: 1.9, 13.3]; P = .02). Ketamine/midazolam produced deeper sedation and higher intraprocedural systolic blood pressure. Hallucinations occurred more frequently with ketamine/midazolam (15 [11.4%] vs five [3.8%]; absolute difference, 7.6 percentage points [95% CI: 1.3, 13.9]; P = .03), though overall procedural comfort, reduced recall, and perceived adequacy of sedation were improved. Procedure-related and sedation-related complications did not differ between groups. Conclusion Radiologist-administered ketamine/midazolam during image-guided procedural sedation improved analgesia and patient-reported experience with fewer hypoxemic events and no increase in complications compared with fentanyl/midazolam. Clinical trial registration no. NCT07040163

Aged↗
PubMed2005

Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures.

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.

Appendectomy↗
PubMed2002

Evolution of operative procedures for the management of morbid obesity 1950-2000.

BACKGROUND: At the turn of the 21st century, obesity is the epidemic with the greatest prevalence in the United States. Fifteen million people, 1 out of 20, in this country have a body mass index (BMI) > or = 35 kgm2. Obesity is not only a medical problem, but also a social, psychological, and economic problem. At present, the morbidly obese are refractory to diet and drug therapy, but have a substantial, sustained weight loss after bariatric surgery. METHODS: This chronology of the landmark operations in bariatric surgery is based on a review of the medical literature. RESULTS: Bariatric surgery can be classified into 4 categories: malabsorptive procedures, malabsorptive/restrictive procedures, restrictive procedures, and other, experimental procedures. The prototype of malabsorptive procedures and the first operation performed specifically to induce weight loss was the jejunoileal bypass. The problems associated with this operation caused its demise. Today's popular malabsorptive procedures are the biliopancreatic diversion and the duodenal switch. Malabsorptive/restrictive surgery currently is predicated on the Roux-en-Y gastric bypass, both the traditional short-limb, and the long-limb for the super obese. Restrictive procedures are represented by the banded and ringed vertical gastroplasty, as well as gastric banding. Experimental procedures include gastric pacing. All of these operations can be performed by open surgery and laparoscopically. CONCLUSIONS: Since bariatric surgery is the only broadly successful treatment for morbid obesity, it is incumbent on all physicians to be familiar with current bariatric operations, and to understand the evolution of bariatric surgery.

Digestive System Surgical Procedures↗
PubMed1999

Propofol anesthesia for invasive procedures in ambulatory and hospitalized children: experience in the pediatric intensive care unit.

OBJECTIVES: To describe our experience with propofol anesthesia to facilitate invasive procedures for ambulatory and hospitalized children in the pediatric intensive care unit (PICU) setting. METHODS: We retrospectively reviewed the hospital records of 115 children who underwent 251 invasive procedures with propofol anesthesia in our multidisciplinary, university-affiliated PICU during a 20-month period. All patients underwent a medical evaluation and were required to fast before anesthesia. Continuous monitoring of the patient's cardiorespiratory and neurologic status was performed by a pediatric intensivist, who also administered propofol in intermittent boluses to obtain the desired level of anesthesia, and by a PICU nurse, who provided written documentation. Data on patient demographics, procedures performed, doses of propofol used, the occurrence of side effects, induction time, recovery time, and length of stay in the PICU were obtained. RESULTS: Propofol anesthesia was performed successfully in all children (mean age, 6.4 years; range, 10 days to 20.8 years) who had a variety of underlying medical conditions, including oncologic, infectious, neurologic, cardiac, and gastrointestinal disorders. Procedures performed included lumbar puncture with intrathecal chemotherapy administration, bone marrow aspiration and biopsy, central venous catheter placement, endoscopy, and transesophageal echocardiogram. The mean dose of propofol used for induction of anesthesia was 1.8 mg/kg, and the total mean dose of propofol used was 8.8 mg/kg. In 13% of cases, midazolam also was administered but did not affect the doses of propofol used. The mean anesthesia induction time was 3.9 minutes, and the mean recovery time from anesthesia was 28.8 minutes for all patients. The mean PICU stay for ambulatory and ward patients was 140 minutes. Hypotension occurred in 50% of cases, with a mean decrease in systolic blood pressure of 25%. The development of hypotension was not associated with propofol doses, the concomitant use of midazolam, or the duration of anesthesia, but was associated with older patient age. Hypotension was transient and not associated with altered perfusion. Intravenous fluid was administered in 61% of the cases in which hypotension was present. Respiratory depression requiring transient bag-valve-mask ventilation occurred in 6% of cases and was not associated with patient age, propofol doses, concomitant use of midazolam, or the duration of anesthesia. Transient myoclonus was observed in 3.6% of cases. Ninety-eight percent of procedures were completed successfully, and no procedure failures were considered secondary to the anesthesia. Patients, parents, and health care providers were satisfied with the results of propofol anesthesia. CONCLUSIONS: Propofol anesthesia can safely facilitate a variety of invasive procedures in ambulatory and hospitalized children when performed in the PICU and is associated with short induction and recovery times and PICU length of stay. Hypotension, although usually transient, is common, and respiratory depression necessitating assisted ventilation may occur. Therefore, appropriate monitoring and cardiorespiratory support capabilities are essential. Propofol anesthesia in the PICU setting is a reasonable therapeutic option available to pediatric intensivists to help facilitate invasive procedures in ambulatory and hospitalized children.

Adult↗
PubMed1999

Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair.

BACKGROUND: Although geographic variations in the rates of orthopaedic procedures have been well documented, considerable controversy remains regarding the factors that drive these variations, particularly the role of the availability of orthopaedic surgeons. Moreover, little attention has been specifically focused on variations in the rates of commonly performed shoulder procedures. METHODS: The current study documents state-to-state variations in the rates of total shoulder replacement, humeral head replacement, and rotator cuff repair and examines factors that might account for these variations. The regional incidences of these three procedures were analyzed with use of the Health Care Financing Administration Medicare database (MEDPAR, 1992). The rates were age-adjusted, and variations were measured with use of high:low ratios, variation coefficients, and systematic components of variation. Potential causes of variation were analyzed with use of Spearman and partial correlations as well as with Poisson regression. RESULTS: Rates for the three procedures that were studied varied from one state to another by as much as tenfold. Humeral head replacement had the lowest rate of variation according to all three measures. All three procedures were performed less often in states that were more densely populated. With the numbers available for study, no consistent, significant relationship was found between the density of orthopaedists and shoulder surgeons and the rates of any procedure. CONCLUSIONS: The striking variations that were noted for these commonly performed procedures showed that there is a clear need for well designed clinical research to further define the factors that account for the variations and to examine the effectiveness and appropriate indications for the procedures.

Aged↗
PubMed1998

Outcomes of noncardiac surgical procedures in children and adults with congenital heart disease. Mayo Perioperative Outcomes Group.

OBJECTIVE: To assess the outcomes and risk factors for morbidity associated with anesthesia and noncardiac surgical procedures in children and adults with congenital heart disease. DESIGN: We conducted a retrospective cohort study of the 6-year period from January 1987 through November 1992 at one of the Mayo-affiliated hospitals in Rochester, Minnesota. MATERIAL AND METHODS: In all children and adults 50 years of age or younger with congenital heart disease who underwent one or more noncardiac surgical or diagnostic procedures and anesthesia, we analyzed the risk factors for 30-day perioperative morbidity and mortality. RESULTS: The overall frequency of complications among the 276 patients who underwent 480 noncardiac surgical procedures and anesthesia was 5.8% (28 of 480), and only 1 patient died intraoperatively. Major risk factors univariately associated with complications for the first procedures (15 of 276 patients or 5.4%) included the presence of cyanosis (P = 0.002), current treatment for congestive heart failure (P<0.001), poor general health (P<0.001), and younger age at the time of the procedure (P = 0.027). Procedures performed on the respiratory and nervous systems also were associated with high frequencies of complications. Complications in patients undergoing ambulatory surgical procedures were infrequent (1.7%). CONCLUSION: The frequency of perioperative complications in children and adults who have congenital heart disease and undergo noncardiac surgical procedures and anesthesia is low. Patients who have pulmonary hypertension, congestive heart failure, or cyanosis and children with congenital heart disease who are younger than 2 years of age have an increased frequency of perioperative morbidity.

Adolescent↗
PubMed2004

[Immediate results of palliative surgery for different forms of univentricular heart using the Norwood procedure].

BACKGROUND: Norwood procedure is used as the first stage in the palliative treatment of the hypoplastic heart syndrome and can be used, with some technical modifications, in other forms of univentricular heart with aortic stenosis or hypoplasia. These patients have a high mortality (50%), derived from the procedure itself and from their abnormal physiological status. AIM: To report our experience with the Norwood procedure. PATIENTS AND METHODS: Retrospective analysis of all patients subjected to the Norwood procedure between February, 2000 and June 2003. RESULTS: Thirteen patients (9 females, age range 5-60 days and median weight of 3.3 kg) were operated. Eight had hypoplastic heart syndrome and five had a single ventricle with aortic arch hypoplasia. The diagnosis was done in utero in eight patients. All technical variations, according to the disposition and anatomy of the great vessels, are described. Cardiac arrest with profound hypothermia was used in all and regional cerebral perfusion was used in nine. Three patients died in the perioperative period and three died in the follow up (two, four and 10 months after the procedure). Gleen and Fontan procedures were completed in five and one patients, respectively. CONCLUSIONS: Our results with the Norwood procedure are similar to other series. There is an important mortality in the immediate operative period and prior to the Glenn procedure.

Abnormalities, Multiple↗
PubMed2001

[Indications for and clinical outcome of the Ross procedure: a review].

The Ross procedure has been used increasingly to treat aortic valve disease in children and young adults. The primary indication for the Ross procedure is to provide a permanent valve replacement in children with congenital aortic stenosis. More recently, it has been extended to young adults with a bicuspid aortic valve and small aortic annulus, especially women wishing to have children. Other possible indications include complex left ventricular outflow obstructive disease, native or prosthetic valve endocarditis, and adult aortic insufficiency with a dilated aortic annulus. Conversely, Marfan syndrome is considered to an absolute contraindication, and this procedure should be used with caution in patients with rheumatic valve disease and a dysplastic dilated aortic root because of the higher associated incidence of autograft dysfunction. The technique of total aortic root replacement has become the preferred method of autograft implantation, because it carries the lowest risk of pulmonary autograft failure. In patients with marked graft-host size mismatch, either concomitant aortic annulus reduction and fixation or aortic annulus enlargement (i.e., the Ross-Konno procedure) should be performed. The Ross Procedure International Registry data document that in the modern era (post-1986) the early and late mortality rate is 2.5% and 1%, respectively. Excellent long-term results have been reported, and the benefits of this procedure include optimal hemodynamics, low risk of endocarditis, resistance to infection in patients with active endocarditis, and nonthrombogeneicity and therefore few anticoagulation-related complications. The Ross procedure can be performed with acceptable early and mid-term mortality and excellent autograft durability. Further long-term follow-up will confirm the role of this procedure in patients with various types of aortic valve disease.

Adult↗
PubMed2003

Sedation with midazolam and ketamine for invasive procedures in children with malignancies and hematological disorders: a prospective study with reference to the sympathomimetic properties of ketamine.

Different pharmacological agents have been used for sedation in children undergoing invasive procedures. The authors prospectively evaluated the efficacy, the occurrence of adverse side effects, and cardiovascular parameters in midazolam and ketamine sedation for invasive procedures in children with malignancies and hematological disorders. A total of 183 invasive procedures were performed on 63 children (mean age 9.2 +/- 5.2 years). Intravenous sedation consisted of 0.1 mg midazolam/kg and 1.0 mg ketamine/kg. Incremental dosages of ketamine (0.33 mg/kg) were given if necessary to maintain deep sedation. Systolic and diastolic blood pressure, heart rate, and oxygen saturation were recorded. All 183 invasive procedures were successfully completed with satisfactory sedation levels in 170 procedures (92.9%; 95% CI:88.2-96.2%). In 33 procedures (18%; 95% CI: 12.8-24.4%) sedation was associated with side effects, the most common being oxygen desaturation. One patient experienced a transient episode of laryngospasm. There was a significant increase in both systolic and diastolic blood pressure and heart rate after ketamine medication (p <.01). Procedure and recovery time were correlated to ketamine dosage (p <.01). The combination of midazolam and ketamine is efficacious in achieving deep sedation for painful invasive procedures. Considering the possibility of potentially serious respiratory complications it should be performed only by physicians who are trained in advanced airway management and life support. As opposed to many other sedative drugs with cardio-depressant properties, ketamine causes a rise in both systolic and diastolic blood pressure, and heart rate.

Anesthetics, Combined↗
PubMed1992

Risk of hepatitis B and human immunodeficiency virus transmission to a patient from an infected surgeon due to percutaneous injury during an invasive procedure: estimates based on a model.

The objective was to estimate the probability of sporadic hepatitis B virus (HBV) and human immunodeficiency virus (HIV) transmission to a patient from an infected surgeon due to percutaneous injury during an invasive procedure. Risk was estimated based on a model involving three probabilities: A, the probability that the surgeon will sustain a percutaneous injury during an invasive procedure; B, the probability that the sharp object causing the injury and now contaminated with the surgeon's blood will contact the patient's wound; and C, the probability that infection would be transmitted to the patient after such an exposure. The probability of transmission during one procedure is p = A x B x C. The probability of transmission to at least one patient during N procedures is 1-(1-p)N. Values for A, B, and C were estimated from prospective studies. The estimated probability of transmission from an infected surgeon to a patient during a single procedure is 0.00024-0.0024% for HIV and 0.024-0.24% for HBV if the surgeon is positive for hepatitis B e antigen (HBeAg). The estimated probability of transmission to at least one patient during 3,500 procedures (estimated to be performed during an HIV-infected surgeon's remaining working life) is 0.81-8.1% for HIV; 57-100% for HBV if the surgeon is an HBeAg carrier. These estimates represent population averages and may not necessarily apply to a particular procedure performed by a particular surgeon, for which the risk may be considerably lower or higher than the estimated average. This risk assessment, which is based on limited data and does not take clusters of transmission into account, predicts that the risk of sporadic HBV transmission from infected surgeons to patients due to percutaneous injury during an invasive procedure is small and that the risk of HIV transmission is less than that for HBV. More data are needed to understand both sporadic and epidemic transmission in order to further reduce patient risk.

Carrier State↗